Morning Report

New Patient Mrs. M / 44 yo at ER Saiful Anwar Hospital (EM)

No

SUBJECTIVE

OBJECTIVES

ASSESSMENT

TREATMENT

1
Augus
t 16th
2014
16.42

SOB

Physic Diagnostic :
BP 87/67 PR 120 bpm
RR 26x/ t 36.1C
Airway: patent, clear
Breathing: tachypneu
Circulation: warm &
dry acral
Blood glucose:60

1. SOB dt ADHF
2. Lung TB drop
out

Bedrest,
semifowler
position
O2 10 lpm NRBM
IVFD NS 0.9% life
line
Inj Ranitidin 50mg
IV
Inj D40% 25 ml IV
Drip NE start 0.05
mcg/kgBW/min
Dispose to Cardio

New Patient Mrs. M / 44 yo at ER Saiful Anwar Hospital

No

SUBJECTIVE

OBJECTIVES

ASSESSMENT

TREATMENT

1
18.1
5

Bloody cough
Bloody cough in th
afternoon 3x. History
of DOE (+) since 4
years
ago
intermittently
when
doing heavy activity.
Orthopneu (+), PND
(+), leg swelling (-),
chest
pain
(-),
palpitation (-).
History of HTN (-)
History of DM (-)
History
of
hospitalization (-)
History of controlled
in Pulmonology and
Internal
outpatient
clinic
in
Bangil
hospital (+) but she
didnt know the name
of the drugs.
History of 6th months
medication (-).
She had 4 children
and
had
normal
labour.
History
of
moving

Physic
Diagnostic :
BP 86/61 PR 145
bpm RR 26x/ Sat
O2 100% NRBM
JVP
R+
2cm
H2O(45)
Rh - Wh - - ++
-Ictus
visible,
palpable at ICS VII
1 cm lat MCL S,
S1S2 N, M (?) sde,
gallop (-)
Abd flat, soefle,
BS
(+)N,
liver
span 8cm
Leg edema -/-,
cold acral
Thorax USG:
-LA,
RA,
RV
dilatation,
Lvnormal
- Doming AML

1. Shock

PDx:
- Echocardiography
- ECG serial, DL, UL, Ur, cr,
SE, OT/PT, Albumin, lipid
profile, UA
- USG abdomen

2.
3.
4.
5.

1.1
Cardiogenic
1.2 Non
cardiogenic
Septic
condition
MSI
3.1 RHD
sequalae
HF st C fc IV
4.1 MSI
Hemoptoe dt
?

6.
Hyponatremi
a
7.Hypoalbumin
emia
8. Azotemia
9.
Increase
transaminas
e

PTx:
Bedrest, semifowler position
O2 10 lpm NRBM
Total fluid intake 1500cc/24h
IVFD NS 0.9% 500cc/hr
Fluid balance neg 500 cc/24h
Drip NE 0.05-2mcg/kgBW/min
Drip
Dobutamin
3-15
mcg/kgBW/min
Inj Furosemide 40-0-0 mg
Inj Ceftriaxon
2x1 g (skin
test)
Inj. Digoxin 1x0.25 mg IV
PO:
Spironolacton 0-25-0 mg
N Acetyl Cystein 3x1 sachet
Laxadin 0-0-C1
Alprazolam 0-0-0.5 mg
Move to CVCU

ECG in ER (16/8/14, WIB)

CXR 29-6-2014

AP position, asymetric, KV enough, enough inspiration

Trachea in the middle
Soft tissue thick and bone normal
Right are and left phrenico-costalis angle are sharp
Right and left hemidiaphragm are domeshaped
Lung: infiltrate in the medial of rightand sinistra lung
Cor: CTR: 65% cardiac, dilatation all chamber
Conclusion: cardiomegaly

Laboratory Finding at ER
Lab

value

Normal
value

Leuco

16.700

3.500-10.000

Hb

12.90

11-16.5

Thromb
o

1427.000

PCV

Value

Norm
al
value

127

136145

3.57

3,5-5

150-390.103

Cl

106

98-105

36.80

35-50

Ureum

CPK

390

26-192

Creatini
n

2.5

0,7-1.2

CKMB

38

7-25

Albumin

2.8

3,5-5,5

Trop I

0.2

<1

SGOT

1120

11-41

2.4-5.7

SGPT

694

10-41

Uric
acid
Chol/TG
/HDL/LD

<200/<150/>50/
<100

Lab

Na

10-50

Neutrofil 77.1%

BLOOD GAS ANALISIS with NRBM 8 lpm

pH
pCO2
pO2
HCO3
O2 sat
BE

7. 34
:
23.4 mmHg
:
104.3 mmHg
:
12.7 mmol/L
:
97.8 %
:
-13.3 mmol/L

Summary data base at CVCU

Chief Complain : Bloody cough

Bloody cough in th afternoon 3x. History of DOE (+)

since 4 years ago intermittently when doing heavy
activity. Orthopneu (+), PND (+), leg swelling (-), chest
pain (-), palpitation (-).
History of HTN (-)
History of DM (-)
History of hospitalization (-)
History of controlled in Pulmonology and Internal
outpatient clinic in Bangil hospital (+) but she didnt
know the name of the drugs.
History of 6th months medication (-).

Summary data base at CVCU

(contd)

She had 4 children and had normal labour.

History of moving joint pain (-).
History of decxrease appetite (+), history
decrease body weight (-).

of

TIME LINE
4 years
ago

SOB when
doing heavy
activity

HF st C FC III

2 days

SOB
worsened,c
ough (+),
whitthish
sputum

HF st C fc III
pneumonia

1 day before
admission

Worsening of SOB,
bloody cough,

HF st C fc IV
admitted

Physical Examination at Ward

General
appearance
Blood Pressure

Looked moderately ill, CM

Looks normoweight
Sat O2 100% (10lpm
NRBM)

BP 100/80

Pulse Rate

122 Bpm

Respiratory rate

24 tpm

Head

Anemic (- ), Icteric (-),

Neck

JVP + 2 cm H2O 450 position

Thorax

Ictus invisible palpable in ICS VII 1 cm lat MCL S

RHM = SL D. LHM = ictus
S1S2 N, m (+) systolic, gr II/VI, PM at apex
radiated to axilla gallop (-), heaves -

Heart

Lung

Symmetric

v
v v
v v

Rh - - Wh - - -+ +
--

Abdomen

Flat ,Soefl, met -, Bowel sound Normal, liver span

9cm, traube space tympani

Extremities

Leg swelling +/+, warm acral

ECG in CVCU (17/08/14,

16.00WIB)

CUE & CLUE

P. LIST

Mrs. M / 44 yo
- SOB
- Orthopneu
- Dyspneu d
effort
- PND
- Not relieved by
rest
- Bloody chough
PDx:
-T: 100/80 mmHg;
PR: 122x/m RR
284 tpm
-Cardiomegaly,
murmur (+)
-Rh at all basal
lung D&S
- Oedem lower
extremity
ECG: Sinus
tachycardia HR
122 bpm
CXR:
Cardiomegaly,
Lab:
hiponatremia,
hipoalbuminemia,

1. Post
shock

I Dx
1.1
Cardi
ogeni
c
1.2
Non
cardi
ogeni
c

P Dx

P Th

P Mo

-Echoca
rdiogra
phy
ECG
serial,
-- lipid
profile,
UA

PTx:
Bedrest,
semifowler
position
O2 10 lpm NRBM
IVFD NS 0.9% 500cc/hr
Drip
NE
0.052mcg/kgBW/min
Drip
Dobutamin
3-15
mcg/kgBW/min
Inj Furosemide 40-0-0 mg
Inj Ceftriaxon 2x1 g (skin
test)
Inj. Digoxin 1x0.25 mg IV
PO:
Spironolacton 0-25-0 mg
N Acetyl Cystein 3x1
Laxadin 0-0-C1
Alprazolam 0-0-0.5 mg

Subje
ctif
BP
PR
RR
Urine
Produ
ction

CUE & CLUE P. LIST

Mrs.M/ 44
yo
- SOB
- Orthopneu
- Dyspneu d
effort
- PND
Chough since
2 days, fever
History of
HTN >10
years
PDx:
-T:
100/80mmHg
; PR: 122x/m
RR 24 bpm
Cardiomegaly
-Rh at all area
lung D&S
- Oedem
lower
extremity
ECG: Sinus
tachycardia
HR 122 bpm
CXR:
Cardiomegaly

2.

Septic
condition

I Dx

P Dx

P Th

P Mo

Blood culture
& sensitivity

Bedrest, semifowler
position
O2 10 lpm NRBM
IVFD NS 0.9%
500cc/hr
Drip
NE
0.052mcg/kgBW/min
Drip Dobutamin 3-15
mcg/kgBW/min
Inj Furosemide 40-0-0
mg
Inj Ceftriaxon 2x1 g
(skin test)
Inj. Digoxin 1x0.25
mg IV
PO:
Spironolacton 0-25-0
mg
N Acetyl Cystein 3x1
sachet
Laxadin 0-0-C1
Alprazolam
0-0-0.5
mg

Subjectif
BP
PR
RR

CUE & CLUE

P. LIST

Mrs. M/ 44 yo

3. MS

-SOB
- Orthopneu
- Dyspneu d

effort
- PND
- Not relieved by
rest
- Bloody chough
PDx:
-T: 100/80 mmHg;
PR: 122x/m RR
284 tpm
-Cardiomegaly,
murmur (+)
systolic -Rh at all
basal lung D&S
- Oedem lower
extremity
ECG: Sinus
tachycardia HR
122 bpm
CXR:
Cardiomegaly,

I Dx

3.1 RHD
sequa
lae

P Dx

P Th

P Mo

Echocardio
graphy

Bedrest, semifowler
position
O2 10 lpm NRBM
IVFD NS 0.9%
500cc/hr
Drip
NE
0.052mcg/kgBW/min
Drip Dobutamin 315 mcg/kgBW/min
Inj Furosemide 400-0 mg
Inj Ceftriaxon 2x1
g (skin test)
Inj. Digoxin 1x0.25
mg IV
PO:
Spironolacton 0-250 mg
N Acetyl Cystein
3x1 sachet
Laxadin 0-0-C1
Alprazolam 0-0-0.5
mg

Subjectif
BP
PR
RR

CUE & CLUE

P. LIST

I Dx

Mrs. M / 44 yo
-SOB
- Orthopneu
- Dyspneu d effort
- PND
- Not relieved by rest
- Bloody chough
PDx:
-T: 100/80 mmHg;
PR: 122x/m RR 284
tpm
-Cardiomegaly,
murmur (+) systolic
-Rh at all basal lung
D&S
- Oedem lower
extremity
ECG: Sinus
tachycardia HR 122
bpm
CXR: Cardiomegaly,

4. HF st 4.1 MS
C
fc
IV

P Dx

P Th

P Mo

eCHOC
ARDIO
GRAPH
Y

Bedrest, semifowler
position
O2 10 lpm NRBM
Total fluid intake
1500cc/24h
IVFD NS 0.9%
500cc/hr
Fluid balance neg
500 cc/24h
Drip
NE
0.052mcg/kgBW/min
Drip Dobutamin 3-15
mcg/kgBW/min
Inj Furosemide 40-00 mg
Inj Ceftriaxon 2x1 g
(skin test)
Inj. Digoxin 1x0.25
mg IV
PO:
Spironolacton 0-25-0
mg
N Acetyl Cystein 3x1
sachet
Laxadin 0-0-C1
Alprazolam
0-0-0.5
mg

Subje
ctif
BP
PR
RR
Urine
Produ
ction

CUE & CLUE

P. LIST

Mrs. M / 44
yo
Bloody cough

5.

Mrs. M / 44
yo
Na: 127

6.

I Dx

P Dx

P Th

P Mo

Treat underlying disease

Subj

Treat underlying disease

SE/3
days

Hemo
ptoe
dt ?

Hypon
atremi
a

P Th

P Mo

7.Hypoalb
umine
mia

Treat underlying disease

Subje
ctif
BP
PR
RR

Mrs. M / 44 yo
Cr: 2.5
BUN 129

8.

Treat underlying
disease

Ur,
Cr
per 3
days

Mrs. M / 44 yo
OT/PT: 1120/694

9.

Treat underlying disease

OT/PT
per
3days

CUE & CLUE

P. LIST

Mrs. M / 44 yo
Alb: 2.80

Azotem
ia

Increas
e
transa
minase

I Dx

P Dx

ECG in CVCU (18/8/14,

05.00 WIB)

This Morning 06.00

Subjective : SOB decrease

BP :113/70
HR: 140
bpm
RR : 20
tpm
Urine : 60
cc/hr